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� <br /> 1 <br /> � <br /> � . <br /> BG�ckwater Prevention Device <br /> E� � Rebate Program ' <br /> i <br /> z <br /> i <br /> Vendor Section (please print): � <br /> - ---- --- - _ _- - . _ .__ ; <br /> � �• i� , . j <br /> ((�it�e:s=F' ,�,.r,�i��ie.il��J_i� e'� i �� -'' __- /f:���- . .��.�L'..� _._ ' �� � <br /> �-- —�- - - <br /> Vendor Name 1 Business Name 1 UE31 Nunibc�r i <br /> �iGr_l<. ('"�--�1(� J-/�l(i� <br /> _ - .--.- .. . <br /> State of Washington Conlracfor Lir.ense Number � <br /> � • � , . <br /> • 9 , " _ � -� /, �J`_. 'J + <br /> _ �, ` <br /> ��i �� (�/' �� . . V /_�.1�c %irvcri�� Li;�'r � C J �' ; <br /> --- -- _ ----fb---_._'_ <br /> Vendor Mailing Address �i}y ;:�a�e �ip ; <br /> "ll�--_) ,��-J�ti � . . �i<'f i_l"�IJiP/frc.'f��C`,U%i r�`C ( !D� ,C'C.�._', � . <br /> Phone Finail � <br /> _ ---_ ---- ----J ' <br /> I, the Vendor, agree to receive the [3ackwater Prevention Device rebale check direclly , <br /> (or the installation re(erenced at the Property nddress. By ayreeing to receive the rebate <br /> chech directly, I agree to the following: � <br /> 1. The f3achwaler Prevenlion Device rebafe amount will be dedur,ted from the finai <br /> invoice yiven to lhe Property Owncr for the installalion at thc Property Addreas <br /> referenced ai�ove, iF tfie toial cost of the installation is greater than the reh�le. � <br /> `L. I, the Vendor, am a Washington Stale licensed conlractor. � <br /> 3. The City of Everelt will send a Federal Form 1099 MISC to rne, lhc Vendoi, (or <br /> the Backwaler Prevenlion Device rebate paymenls totaling more than $G00 per ' <br /> calendar year, .:r�d will report lhe same payments to the Inlernal Revenue � <br /> Servic�:. <br /> i <br /> I accept the direcl payment of the E3ackwater 1'revention Device «�bate from the City I <br /> � <br /> of �verett pendiny approval o( lhe �ornpletecl f3,�ckw,�ter Prevention Uevic�� rehale � <br /> pack..ye by ihe City of Fvercll ; <br /> t <br /> \ ' � <br /> J � - -� ; <br /> . f � <br /> , <br /> /�;�.•� ��/�� ' (�. ����'L°' � - � /Z Z / 5 � <br /> .: <br /> / / / <br /> ..�`'��naturen(Cunlrnr.(i>�- =-- --�--- . _. __ �.._ !);dc - -. . <br /> i <br /> � <br /> � <br /> t <br /> i <br /> I <br /> I <br /> i <br /> (';iyr 2 �i12 � <br /> f�cvi;r„I +!':;/20!4 � i <br />